Social Worker - Home Based Primary Care (HBPC)

US-Department-of-Veterans-Affair; Dayton (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

US Department of Veterans Affairs in Dayton, OH seeks a HBPC Social Worker to join a multidisciplinary team delivering in-home primary care for Veterans with complex medical and psychosocial needs. You will provide intensive case management, caregiver support, and care coordination with community partners, assessing needs and developing tailored treatment plans to maximize independence and well-being.

Collaboration with other professionals, advocacy for Veterans and families, and dynamic home

Qualifications

• Experience coordinating care across multiple providers and settings.
• Strong assessment, communication, and documentation skills.
• Knowledge of community resources and referrals.
• Understanding of psychosocial factors affecting health outcomes.

Responsibilities

• Provide intensive case management and caregiver support.
• Collaborate with multidisciplinary teams for care coordination and service mobilization.
• Independently assess psychosocial needs and develop tailored treatment plans.
• Link Veterans with community resources and services to maximize independence.
• Conduct home visits and advocate for Veterans and families.

Skills

Interdisciplinary teamwork

Case management

Care coordination

Crisis assessment

Education

Master's in Social Work (CSWE accredited)

Job description

The HBPC Social Worker is a member of a multidisciplinary team providing interdisciplinary primary care in the homes of Veterans with serious medical & psychosocial behavioral conditions for whom routine clinic based care is not effective or may not be possible. They provide intensive case management & caregiver support. They also collaborate with community partners & other professional agencies in care coordination & mobilization of tailored services for the Veteran or caregiver. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency. Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f).
• Education. Have a master's degree in social work from a school of social work fully accredited by the Council on Social Work Education (CSWE). Graduates of schools of social work that are in candidacy status do not meet this requirement until the school of social work is fully accredited. A doctoral degree in social work may not be substituted for the master's degree in social work.
• Licensure. Persons hired or reassigned to social worker positions in the GS-185 series in VHA must be licensed or certified by a state to independently practice social work at the master's degree level. Current state requirements may be found by going to http://vaww.va.gov/OHRM/T38Hybrid/

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

Social Worker, GS-11

(1) Experience and Licensure

Appointment to the GS-11 grade level requires completion of a minimum of one year of post-MSW experience equivalent to the GS-9 grade level in the field of health care or other social work-related settings, (VA or non-VA experience) and licensure or certification in a state at the independent practice level. NOTE: For appointment licensure or certification at this level please refer to paragraph 3c.

OR

Education. In addition to meeting basic requirements, a doctoral degree in social work from a school of social work may be substituted for the required one year of professional social work experience in a clinical setting.

(3) Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, candidates must demonstrate all of the following KSAs:

• (a) Knowledge of community resources, how to make appropriate referrals to community and other governmental agencies for services, and ability to coordinate services.
• (b) Skill in independently conducting psychosocial assessments and treatment interventions to a wide variety of individuals from various socio-economic, educational, and other backgrounds.
• (c) Knowledge of medical and mental health diagnoses, disabilities and treatment procedures (i.e. acute, chronic and traumatic illnesses/injuries, common medications and their effects/side effects, and medical terminology) to formulate a treatment plan.
• (d) Skill in independently implementing different treatment modalities in working with individuals, families, and groups who are experiencing a variety of psychiatric, medical, and social problems to achieve treatment goals.
• (e) Ability to provide consultation services to new social workers, social work graduate students, and other staff about the psychosocial needs of patients and the impact of psychosocial problems on health care and compliance with treatment.

(4) Full Performance Level Assignments

This is the full performance level. Social workers at this level are licensed or certified to independently practice social work. Incumbents are assigned to all program areas, including but not limited to: inpatient or outpatient medicine, surgery, mental health, neurology, rehabilitation medicine, and geriatrics. Employees provide professional, independent social work services in the assigned area. Duties include but are not limited to: assessing and documenting identified behaviors or symptoms of abuse, neglect, exploitation and/or intimate partner violence; use of clinical social work skills and knowledge to maintain Veteran privacy and confidentiality per policies, handbooks or directives; and acts as an advocate with appropriate VA and community service providers and agencies when it serves the best interest of the Veteran and family members/caregiver. Incumbent independently assesses the psychosocial functioning and needs of Veterans and their family members, identifying the Veteran's strengths, weaknesses, coping skills, and psychosocial acuity. In collaboration with the Veteran, family/caregiver, and interdisciplinary treatment team, the social worker facilitates the delivery of health care services. The social worker identifies family/caregiver stressors, conducts assessment and provides specific interventions. The incumbent provides case management and care coordination to facilitate appropriate delivery of health care services, incorporates complex multiple causation in differential diagnosis and treatment of Veterans, including making psychosocial and psychiatric diagnoses within approved clinical privileges or scope of practice. The social worker links the Veteran with services, resources, and opportunities, in order to maximize the Veteran's independence, health, and well-being. The social worker conducts timely assessment of at-risk Veterans in crisis to identify immediate needs, evaluate risk, and initiate safety plan as appropriate. The social worker provides interventions independently with Veterans and their families/caregivers who are experiencing a wide range of complicated medical, behavioral health, financial, legal, and psychosocial problems. They provide a range of interventions and treatment modalities which may include individual, group, and/or family counseling or psychotherapy. They independently formulate and implement a treatment plan including measurable, achievable goals identifying the Veterans' needs, strengths, weaknesses, coping skills, and psychosocial acuity. Social workers serve on committees, work groups, and task forces at the facility and VISN level or in the community. They provide subject matter consultation to colleagues and students on the psychosocial treatment of Veterans offering professional opinions based on experience, expertise and role modeling effective social work practice skills. The social worker establishes and maintains ongoing education programs for Veterans, community agencies, students, and staff, to facilitate understanding of social work interventions specific to the Veteran/Military population.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is G-11. The actual grade at which an applicant may be selected for this vacancy is GS-11

Physical Requirements: R required to sit and stand for at least eight hours. Also, ride in a car to complete home evaluations with supervised staff. Able to lift 10 - 25 pounds of supplies related to the HBPC program.